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MyChart Authorization for Use and Disclosure of Electronic Protected Health Information and Mount Sinai Medical Center Notice of Privacy Practices and MyChart Terms and Conditions of Use

The hospital's Notice of Privacy Practices can found under the Notice of Privacy Practices Section of this document.
A paper copy of this document can be obtained by selecting the Terms and Conditions hyperlink after logging into MyChart and selecting the print icon.

I understand that the records subject to this authorization include any and all records which pertain to my diagnosis, treatment or care including, without limitation face sheet(s), history and physical examination(s), admission note(s), discharge summary(ies), radiology and laboratory testing, consultation report(s), progress notes, physicians’ orders, medication/prescription records, operative and procedure notes, nursing notes, and similar records. I understand that this authorization will extend to medical records prepared or kept by third-party healthcare providers which are contained within the medical records of Mount Sinai.

I understand that the records subject to this authorization may include (if applicable) information relating to sexually transmitted diseases (“STDs”), acquired immunodeficiency syndrome (HIV/AIDS); behavioral and mental health services (including communications with psychiatrists and psychotherapy notes), records of treatment for alcohol and substance abuse, and results of genetic (DNA) testing.

I understand that any disclosure of health information carries with it the potential for an unauthorized re-disclosure, and that any information which is re-disclosed may not be protected by federal or state privacy laws. I hereby agree to release and hold Mount Sinai Medical Center harmless for complying in good faith with this Authorization.

I understand that this authorization shall remain in effect until revoked. I understand that I have a right to revoke this authorization at any time, except to the extent that action has been taken by Mount Sinai Medical Center in reliance on it. Patients may request deactivation of an account by sending an e-mail to our MyChart Support Staff at MyChartSupport@msmc.com and be sure to include your phone number and contact information. It is understood that any such revocation will not be effective until received by the MyChart Support Staff at Mount Sinai Medical Center.

I understand that this authorization is voluntary, and that my refusal to sign this authorization will not affect my eligibility for health care services or treatment in any way.

Notice of Privacy Practices

Effective Date: January 25, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact the Facility Privacy Official by dialing 305-674-2722.

THIS NOTICE COVERS
Mount Sinai Medical Center provides health care to patients jointly with physicians and other health care professionals and organizations. Mount Sinai Medical Center and the individual described below together are sometimes called “us” or “we” in this Notice.
The privacy practices described in this Notice apply to all impatient and outpatient departments, units and programs of Mount Sinai Medical Center, whether located on or off the main campus of the hospital, and will be followed by all employees, staff, trainees, students, volunteers and other hospital personnel who have a need to use your health information to perform their job, including physician members of the medical staff and allied health professional while they are caring for you in the hospital.
The individuals described above may share your health information with each other to carry out treatment, payment, or health care operation related to your care. This Notice explains generally how this hospital and the individuals described above might share or disclose your health information.
This Notice does not cover services provided in the private offices of physicians.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
Each time you visit a hospital, physician, or other healthcare Provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment.

Means of communication among the many health professionals who contribute to your care.

Document describing the care you received.

Means by which you or a third-party payer can verify that services billed were actually provided.

A tool in educating health professionals.

A source of data for medical research.

A source of information for public health officials charges with improving the health of the nation.

A source of data for facility planning and marketing.

A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

Make more information decisions when authorizing disclosure to others.

YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on certain users and disclosures of your information as provided by 45 CFR 164.522

Obtain a paper copy of the notice of information practice upon request

Inspect and copy your health record as provided for in 45 CFR 164.528

Amend your health record as provided in 45 CFR 164.528

Request communications of your health information by alternative means or at alternative locations

Request that we restrict certain disclosures of information in your health record to your health plan with respect to health care items or services for which you, or someone other than your health plan, have paid in full

Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

OUR RESPONSIBILITIES
This organization is required to:

Maintain the privacy of your health information.

Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.

Abide by the terms of this notice.

Notify you if we are unable to agree to a requested restriction.

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

Notify you in the event that it has been determined that a breach of the privacy of your health information has occurred.

Not disclose psychotherapy notes which are maintained by us without your authorization.

Not disclose your health information under circumstances which would constitute a sale of such information under 45 CFR 164.508(a)(4) without your authorization.

Although we may change our practices and to make the new provisions effective for all protected health information we maintain, if we do change our information practice we will post a revised copy on our facility web site.
We will not use or disclose your health information without your authorization, except as described in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions and would like additional information, you may contact the Director of Health Information Management at 305-674-2320.
If you believe your privacy rights have been violated, you can file a complaint by contacting the Privacy Officer at 305-674-2722, or with the Secretary of Health and Human Services, Office of Civil Rights. There will be no retaliation for filing a complaint.

EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
We will use your health information for treatment.
For Example: Information obtained by a nurses, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physicians will document in your record his or her expectations of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.
We will also provide your physician or a subsequent healthcare provider with copies various reports that should assist him or her in treating you once you’re discharge from this hospital.
We will use your health information for payment.
For Example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as, your diagnose, procedures, and supplies used.
We will use your health information for regular health care operations.
For Example: Members of the medical staff, our risk or quality improvement manager, or members of our quality improvement team may use information in your health record to assess the care and outcomes in your case and other like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and services we provide.
Business Associates: There are some services provided in our organization through contracts with business associates who create, receive, maintain, or transmit protected health information on our behalf. Examples include certain laboratory tests and transcription services. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and, if appropriate, bill you or your third-party payer for service rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information as specified by a contract that provides the information will be kept confidential.
Business Decision Making: We may combine medical information about many hospital patients in an overview to decide what additional services the hospital should offer, what service are not needed, and whether certain new treatments are effective. We also may disclose information to physicians, nurses, technicians, medical students, and other personnel for review and education. We may combine the medical information we have with medical information from other facility to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
Directory: Unless you notify us that you are object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person who is responsible for you care, of your location and general condition.
Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relatives, close personal friend or any other person you identify, health information to the extent that it is relevant to that person’s involvement in your care or payment related to your care.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health record.
Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we many disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Fund Raising: We may contact you as part of a fundraising effort. Your demographic data and dates of service may be provided to our institutionally related foundation for this purpose. You have the right to opt out of receiving such fundraising communications.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your health information to legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional Institution: Should you be inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Law Enforcement: we may disclose health information for enforcement purpose as required by law or in response to valid subpoena.
Federal law provides that an appropriate health oversight agency, public health authority or attorney may have access to your health information if a work force member or business associate believes in good faith that we have engages in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

PRIVACY: Your privacy is of the utmost importance to us. Mount Sinai Medical Center will use your confidential medical information in order to provide you healthcare services. Healthcare Providers will, at all times, maintain your confidential medical information in strict confidence and will not disclose any information regarding you to any unaffiliated third party, unless you authorize that person to receive your information or the information is permitted or required to be disclosed by law. Please review Mount Sinai Medical Center’s Notice of Privacy Practices for a thorough description of how we gather, use and protect your confidential medical information.

Mount Sinai Medical Center reserves the right to modify this Agreement at any time. Any modifications will become effective immediately upon posting to the Site. You agree that it is your responsibility to review the Agreement periodically to be aware of such modifications, as your continued access or use of the Site shall be deemed your conclusive acceptance of the modified Agreement.